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A curriculum for the psychiatric training of family physicians
A Curriculum for the Psychiatric Training of Family Physicians L. Ralph Jones, M.D. Harry J. Knopke,
Ph.D.
Richard R. Parlour, M.D. Russell L. Anderson,
M.D.
The University of Alabama School of Medicine,
College of Community
Recognizing the important role offamily physicians in mental health care, psychiatry and family medicine faculty developed a psychiatric curriculum for family medicine residents. The collaborative effort utilized graduate interviews, literature review, and specialized group techniques to develop a competency-bused curriculum that begins early in the residency, is integrated longitudinally into the remainder of the curriculum, and utilizes seminars, clinical experience,and liaison with a mental health team in the training design. Abstract:
For a number of years, a consensus has prevailed regarding the need to address decisively the maldistribution of physicians with respect to their specialty or functional role relative to the needs of the population (1, 2). Primary care has become the organizing principle for health care delivery in the 1980s. By serving as physician of first contact, by rendering comprehensive care and continuity of care, and by coordinating health care delivery, the primary care physirian-especially the family physician-was envisioned to be capable of filling the gaps in the American health care delivery system. Coleman and Patrick suggested that the inclusion of mental health services as an integral component of primary health care offers the only feasible means to improve substantially the mental health services for the population as a whole (3). This conclusion was amply supported by the report of
This work was supported in part by National Institute of Mental Health Grant lTOlMH16016-OlAlPI. General Hospital Psychiatry 3, 189-398, lY81 @ Elsevier North Holland, Inc., 1981 52 Vanderbilt Avenue, New York, NY 10017
Health Sciences,
University,
Alabama
the President’s Commission on Mental Health (4). Studies of patients’ attitudes about mental health services also support this role for the family physician (5). Furthermore, even though only 2% of patient visits to nonpsychiatrists involve psychotherapy/therapeutic listening, because of their absolute numbers, these physicians provide fully 46% of all psychotherapy/therapeutic listening offered to patients (6). Hoeper et al. found that patients with mental disorders utilize general health services two to four times more than patients without mental disorders. It was concluded that funding for somatic medical care pays for a significant amount of mental care not defined or reported as such (7). Hesbacher et al. surveyed the prevalence of severely symptomatic psychiatric disorders in six family practices. Independent assessments by patients and their physicians revealed 10 '3'0and 21% prevalence, respectively (8). Weissman et al. found a similar prevalence of psychiatric illness in an urban community. The majority of patients were suffering from depression (9). With the high rate of mental disorder documented in primary care patients, psychiatric educational and service backup will be increasingly needed if the thrust of primary care is to succeed. Although psychiatrists will be needed in increasing numbers for administrative, treatment, consultation-liaison, and education functions, there has been a steady decline in the absolute numbers and percentages of U.S. graduates entering psychiatry (10). Neilsen predicted that less than 2% 189 ISSN
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of all medical students would choose a psychiatric career in 1980 (11). The Health Professions Educational Assistance Act of 1976 severely restricted the number of foreign medical graduates who may enter the United States for residency training. The combination of a drop in the number of residents entering psychiatry and the numbers of foreign medical graduates allowed to enter the field will produce a severe shortage of needed psychiatrists. One result of the shortfall in psychiatric manpower is that primary care physicians’ mental health role expectations are increasing. The characteristics of mental health care delivery have changed radically in the past three decades. Active programs of inpatient treatment, the wide application of psychopharmacologic therapy, the emphasis on community-based care, and right to treatment legislation have all contributed to deinstitutionalization (12). But community-based services in the specialty mental health sector have not developed at a sufficient rate to allow this policy to be implemented fully. Only one-third of community mental health centers planned have been opened (13). It has been charged, furthermore, that community mental health centers have failed to serve the most seriously disabled deinstitutionalized patients (14-16). In the midst of an apparent trend to close the state hospitals and “dump” chronically ill patients onto unprepared communities, the movement to integrate mental health services with primary health care delivery has gained momentum (17). Though the rehabilitation and aftercare role for the family physician has increased in importance, the division of responsibility for maintaining chronically ill patients in the community has remained ill-defined (6).
Mental Health Care Delivery in Alabama Alabama has not been spared from a shortage and maldistribution of physicians. This largely rural state is forty-ninth in physician/population ratio and contains only one-third the national average of psychiatrists per 100,000 population. The state mental health system has been under federal court order for eight years to conform to a detailed set of minimum constitutional standards for adequate treatment of the mentally ill (18). In 1980 it was found to be not in compliance with the order. With 64 % of the population on farms or in small towns, only 23% of the few available psychiatrists and 15% of the physicians generally practice in these areas. Yet the indicators for high risk and increased need for
mental health services, such as qualification for poverty designation, the percentage of aging, overcrowded housing, and high rates of admission to state hospitals, suicide, and alcoholism, are most prevalent in rural areas (19, 20). Undereducated poor people often lack the skill and knowledge to obtain even those services that are available. Per capita income in Alabama is only 80% of the national average, and approximately one-third of the age group over 25 has completed less than nine years of formal education (21). These patients expect general physicians to help them with emotional disorders. The conclusion is inescapable that family medicine residents who will enter the underserved areas of Alabama must be trained to recognize, treat, and properly refer psychiatric patients. The Family Medicine Residency at the University of Alabama College of Community Health Sciences was established in 1974 to prepare physicians to meet the health care needs of rural and underserved areas of the state. The residency had graduated four classes of family physicians when the psychiatry faculty undertook a complete evaluation of their share of the curriculum developed during the first seven years. Through this self-assessment, the faculty determined that additional experiences were needed if graduates of the program were to address the state’s mental health needs and the mental health needs and the mental health manpower shortage in the state and region. To develop efficient and effective psychiatric components for the Family Medicine residency, the psychiatric faculty in the College began a systematic redevelopment of their curriculum, focusing on the following questions: 1.
What are the mental health elements of the professional role of family physicians?
2.
How can these elements of professional roles best be incorporated in the teaching/learning process of the residency?
Program Development Process Early in the faculty’s educational self-assessment, it was decided that the optimal teaching/learning framework would be a competency-based curriculum (22). This provides the means for designing educational experiences around anticipated role functions, and permits maximum flexibility in terms of time, resources, and logistics (23). Because curriculum serves to define professional roles and
Psychiatric
elements of those roles, the process of curriculum development is as significant as its product. Of the many methods described for defining competenties, three were chosen for use in this developmental process, for the amount of information they could provide and their applicability to the residency program: interviews of former residents in practice, a review of the literature, and a modified delphi-nominal group technique (24).
Graduate Resident Interview residents from the first four Representative graduating classes met with College faculty to discuss their experiences in the residency and their professional experiences since they began practice. They represented solo, family practice group, and multispecialty group practices. All the residents felt additional mental health experience to be a priority for the resident curriculum. They were sensitive to mental health problems presented by their patients, but they felt unable to manage many of them adequately. Significant problem areas identified were talking with patients and conducting psychotherapy for marital or divorce problems, sexual problems, psychophysiologic or hypochondriacal complaints. The statement of one graduate summarized these perceptions: “One of the hardest things I have to deal with is the middle-aged woman with a headache.”
Review of the Literature: The Dimensions of a Mental Health Role Efforts to increase the role of the primary care physician in mental health services must recognize the characteristics of their practices. It is noteworthy that patients encountered in urban, sophisticated university hospital services represent only 0.4% of patients seen by physicians and one of 1000 patients at risk each month (25). Ninety to ninetyfive percent of all doctor-patient contacts occur at the primary care level (26). Family physicians see an average of 160 patients in a work week averaging 60 hours, refer only 2.4% of their patients, hospitalize 2%, and provide counseling or psychotherapy in 18% of patient visits (27, 28). Priest estimated that the pragmatic general practitioner spends only seven minutes per psychotherapy patient visit and no more than one hour per month (29). Werkman et al. reported that family physicians encounter the following problems in order of frequency: marital depression, hypochondriasis, alproblems,
Training
of Family
Physicians
coholism, chronic illness, and anxiety-tension states (30). Methods used to deal with emotional and psychiatric illnesses included the following, in decreasing order: advice and reassurance, tranquilizers, antidepressants, sedatives, and psychotherapy (31). Another consideration emphasized by Fisher is the need for the family physician to understand himself (31). A number of issues confront the family physician attempting to deliver effective mental health care. First, he must cope with the personal adjustment to living in an underserved, usually rural area. The processes of personal maturation and professional identity development continue after the physician begins to practice. Problems may arise with his marriage, with his children, or with substance abuse. He may develop an emotional disorder himself, for which he may be reluctant to seek help (32). Any problem that occurs is complicated by his high visibility in rural settings. It may be difficult for a middle-class, urbantrained professional to understand, much less fulfill, the therapeutic requirements of economically disadvantaged, geographically isolated, or ethnically distinct patients (33). Lessons from rural practicing psychiatrists, therefore, are useful (33, 34). The rural family physician providing mental health care must be aware of transference and countertransference feelings and attitudes which occur and must be prepared for the potential complexity of social or business interactions with individuals who are also patients. Physicians practicing in rural areas may feel isolated from support resources and opportunities for professional growth. Unexpected emotional reactions in patients may make the family physician acutely aware of his need for a mental health team or liaison relationship. Traumatic experiences may render the doctor unwilling to diagnose discernible mental disorders, to undertake needed therapeutic measures, or to refer thereafter. Parker and Sorenson have found that inadequate professional support is one of the major reasons why otherwise well-trained and well-motivated physicians leave rural areas for more urban settings (35). These data suggest practical issues in mental health care delivery and areas of important emphasis in mental health curricula for primary care residents. Family physicians must be prepared for a broadly defined role in mental health care delivery and need to be trained to recognize and diagnose mental disorders, to manage certain patients, to recognize indications for referral to psychiatrists, to
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conduct psychotherapy with some patients, to prescribe psychotropic drugs appropriately, to utilize social intervention techniques, and to function as part of an interdisciplinary health team, maintaining professional liaison with other specialists.
Implications for Design of a Curriculm There are many difficulties in constructing a training program which addresses patients’ needs, as well as the scope of preparedness, envisioned for the family physician. Drossman has lamented that the changes in medical education engendered by new technology have emphasized basic science knowledge and technical competence at the expense of understanding mental health dimensions. He doubts whether comprehensive and continuous care can be rendered effectively without these concepts (36). In response, the focus of clinical management in training programs, especially with chronically ill ambulatory patients, has been redirected to behavioral, psychosocial, and psychiatric elements associated with medical disorder in recent years. Brody, however, discovered that primary care physicians, who were informed of inclusion in a study, failed to recognize 79% of their patients’ noncompliance with medications, 34% of psychiatric illness, and 76% of patients’ recent stressful events-even with weekly performance review (37). Possible explanations included attitudinal, knowledge, and skills dimensions, which were not considered adequate justification. McKegney and Weiner believed that these failures result from “irrelevant” features of training programs (38). Much of learning is state dependent; information learned in one state is best recalled in the same state. This means that traditional teaching of psychiatry with “psychiatric” patients on psychiatric services in a specialized context results in little “carry-over learning” of psychiatric principles referrable to nonpsychiatric patients. Training programs have been subsequently designed to weave behavioral, psychosocial, and psychiatric elements into the entire fabric of the curriculum. The best teaching/learning may be achieved in a consultation-liaison setting, with emphasis on biopsychosocial aspects of illness or injury and on the quality of patient interviewing and case formulation (39-41). Engel has further argued that use of the biopsychosocial model has enabled application of the scientific method to areas previously neglected by the biomedical model (42). Interprofessional antagonisms that often de192
velop during training may be minimized by designing collaborative learning experiences in interdisciplinary settings. Learning and efficient utilization of resources for patient care are increased by the availability of respected clinicians who model collaborative professional roles while teaching appropriate knowledge and skills. This approach has been extended from primary care training programs to psychiatry residency, and from psychiatric liaison to medical liaison in psychiatric clinics and hospital units (4346). The NIMH work group on the mental health training of primary care providers has outlined necessary knowledge, attitudes, and skills for construction of educational goals in training programs. The family physician must master a basic core of knowledge that will permit patients to be viewed as whole persons whose biological well-being is associated with their psychosocial well-being. The rationale underlying diagnosis, treatment, or referral in mental disorders must also be understood. Many patients who are most in need of mental health services encounter biased attitudes and avoidance by care givers. These include the old, the poor, members of minority and ethnic groups, the chronically mentally ill, the retarded, or substance abusers. Training programs should offer adequate role models for active involvement with these patient groups, in order to guard against the hopelessness and avoidance these patients often encounter. Some of these attitudinal problems may be addressed in training as a need for greater selfawareness and the ability to avoid overidentification with patients, over-involvement with their problems, moral judgments, and so on. Skills are needed in diagnosis, treatment, prevention, and rehabilitation, with special emphasis on recognition of psychiatric emergencies and serious mental illness. Intrinsic to the contribution of the family physician is the recognition of his or her skill limitations and role boundaries. Another dilemma in designing a curriculum, however, is that no matter how well developed and focused his or her skills, the family physician may encounter inadequate access to secondary and tertiary mental health care backup in many communities. This circumstance will strain the boundaries of the role the family physician is prepared to fill or force patients to forgo services they need (6). Although a consensus exists about the relevance of a consultation-liaison setting for mental health training of family physicians, a framework is required around which to unify the diverse elements
Psychiatric Training of Family Physicians
of the curriculum. Houpt et al. have developed a competency-based model that emphasizes behavioral definitions of competence in knowledge, skills, and attitudes from which behavioral objectives and evaluation methods may be derived. The competency-based model doesn’t adhere to one theoretical or conceptual framework, making it readily applicable to an interdisciplinary training setting. Behavioral objectives may serve as a focus for teaching/supervision in family medicine resident training, such that both teacher and resident are aware of areas of strength and weakness in the mastery of the curriculum. The flexible nature of the competency areas may allow completion of mental health training objectives while rotating on other specialty services (4749). Recently, attention has been focused on the special issues that make evaluation in consultation-liaison programs difficult. Conceptual frameworks for training outcome that consider variability in training environments are proposed which may also be useful for research on curriculum design and its effectiveness (50, 51).
Modified DelphiNominal Group Techniques Family Medicine and Psychiatry faculty met together on a semi-weekly basis over the course of two months to arrive at a mutually defined set of psychiatric/mental health competencies for family practitioners; to determine the requisite educational experiences necessary to meet these competencies in residency; and to resolve necessary and appropriate logistical details. The process employed was similar to the delphi technique in that the same individuals constituted the respondent sample. The process began with a semistructured solicitation compilation of ideas which were subsequently categorized and refined through several iterations (52). The process was also similar to the nominal group process in that the two faculty groups met together each time in the same location and were led in their deliberative process by a moderator (52). Among the role functions and responsibilities mutually identified and described were management of long-term psychiatric patients and their families, crisis counseling, common problems of family life, and sex counseling. As these functions and responsibilities were defined in the form of competencies, a variety of educational experiences and teaching/learning methodologies were established to accomplish them. It was decided that residents would see their family medicine patients requiring mental health care in the psychiatric
suite in the Family Practice Clinic, under the cooperative supervision of the family practice and psychiatric faculty.
Psychiatric Education for Family Medicine Residents Family Medicine Curriculum in Basic Psychiatry The psychiatric
curriculum resulting from this study begins with a two-month block in the first year, constituting part of the program’s core curriculum. The purpose of this block is to establish a knowledge and skill base for the longitudinal, competency-based curriculum. Residents rotate in various clinical settings under close teaching supervision; service and didactic components of the curriculum are balanced to avoid overcrowding either one. Teaching/learning objectives designed to organize basic mental health knowledge, skills, and therapeutic attitudes include the following: 1. Increase skill in psychiatric data gathering, diagnosis, and treatment planning 2. Understand the process of human psychological development, including adaptational hazards and normal and abnormal adaptational variants 3. Recognize and manage psychiatric emergencies 4. Be able to design an appropriate mental health treatment plan in a primary care setting and make adequate referral 5. Learn appropriate methods of collaboration and treatment planning with nonmedical mental health professionals 6. Utilize psychopharmacology and brief therapy modalities in a primary care practice 7. Understand the legal aspects of involuntary treatment and confidentiality 8. Recognize the psychological reactions of the normal patient and his family to the stress of illness or hospitalization Residents spend the first month focusing on the psychiatry dimension of the family medicine program. They see outpatients in the outpatient suites and admit patients requiring hospitalization to the psychiatry unit of a community general hospital. They participate actively in consultation-liaison activities with colleagues on other services and participate in a close working relationship with the community health center serving the catchment area. Health and mental health services are integrated where possible, with the supervised resident 193
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Table 1. Advanced
Psychiatry
Curriculum
Competencies
Competencies 1. Manage long-term
families, including
psychiatric patients and their individual and family counseling
2. Develop skill in crisis counseling priate for family practice 3. Manage common
Method
techniques
Select 3 patients with chronic psychiatric disorders for longitudinal management of at least 6 months each
appro-
Select 2 patients with stress-related disorders; design crisis intervention to reduce symptoms, restore selfesteem, return to effective functioning Work up 1 patient and lead a seminar on sexual disorders
sexual problems
patterns of 4. Recognize normal and dysfunctional family life and develop family counseling skills
Complete an evaluation of one family, including a home visit; interview the family in seminar, explaining the strengths and weaknesses of family functioning, anticipated problems and management
5. Manage common
Participate in seminars on management problems and present a case
problems
of family life
6. Diagnose and manage psychiatric children and adolescents
problems
Evaluate 2 children with psychiatric present diagnostic and management psychiatry seminars
of
7. Understand relationships between psychosocial physical aspects of disease
and
of family life
disorders and issues in child
Work up a case of “illness claiming” months, and present to seminar
behavior,
follow 6
8. Manage psychiatric aspects of chronic disability commonly seen in family practice, including blindness, deafness, cerebral palsy, chronic brain syndrome, mental retardation, or any chronic illness
a. Participate in seminars specifically focused on chronic illness b. Present a case of chronic disability demonstrating appropriate management skills Evaluate 1 student at a school for the developmentally C. disabled for presentation as in (b) above
9. Prepare for and make a court appearance
a. Attend the seminars on psychiatry b. Make at least one court appearance
10. Identify and manage common types of substance seen in family practice including alcoholism
abuse
a. Participate in seminars focused on substance abuse b. Manage for 6 months 1 case of chronic substance abuse and demonstrate understanding of the addiction process and appropriate management; present to seminar C. Attend an AA meeting
11. Recognize and be able to manage the mental health hazards of being a physician
Attend seminars designed to elucidate physicians’ mental health problems; present a case
12. Understand community mental health theory and practices and know how family doctors can participate in community mental health
a. Participate in didactic symposia provided in curriculum b. Visit one community mental health center to observe facilities, staff, patients, and programs
13. Recognize and manage the common syndromes and psychodynamics of occupational psychiatry, evaluation of psychiatry disability, and special management problems presented by these cases
a. Participate in didactic and clinical seminars on occupational psychiatry b. Present a case in which occupational factors are substantially related to mental disorder and propose management
14. Understand the common styles of management and the mental health factors in administration, including the physicians’ office
Participate in seminars ministration
194
on the psychiatric
aspects of ad-
Psychiatric
in a central role in psychiatric evaluation, triage, and treatment. During the second month, residents continue work in outpatient clinics, and they are assigned to a treatment team in an acute care unit of a psychiatric hospital where they manage a small number of seriously ill psychiatric patients under the teaching supervision of a faculty psychiatrist. The residents are expected to learn how to work with the treatment team in evaluation, treatment, and discharge planning on a daily basis and in team meetings. Their tour of duty includes four half-days in an alcoholism treatment unit and four half-days in a psychiatric hospital for children.
Longitudinal,
Competency-Based
Curriculum
This curriculum is based on the expectations that family physicians are principal resources for comprehensive, continuous care to their patients, and that family medicine residents require long-term, ongoing consultation and liaison relationships with psychiatry and behavioral science faculty to implement a biopsychosocial model of illness and injury management. Goals in this training program are defined in terms of competencies, specific tasks embodying knowledge, skills, and attitudes essential to a strong mental health role. Completion of the required competencies may begin on the first day of the residency independent of formal assignment to the psychiatry service; all must be achieved for graduation. With a focus on long-range management, residents often become acquainted with patients from their clinics before diagnosis of an identifiable mental disorder is made, and actively manage these patients in a consultation-liaison teaching relationship with psychiatry, behavioral science, and family medicine faculty. Long-term follow-up of psychiatric patients is another important dimension of this curriculum involving primary, secondary, and tertiary aspects of prevention. It is expected that the majority of competency areas will be addressed in the resident’s experience of outpatient and inpatient treatment of his or her patients. Psychiatry faculty may refer specific cases for residents if needed to complete competency requirements. Conversely, residents may refer some difficult patients for management in the psychiatry clinic as part of the basic psychiatry curriculum. Although methods for attainment of the competenties are specified, considerable flexibility is intended. The resident may choose the timing, the
Training
of Family
Physicians
supervision, and treatment setting in each area. The competencies and their methods of attainment are listed in Table 1. Every Wednesday afternoon, a combined clinical and didactic meeting is held, attended by psychiatry and behavioral science faculty who function in a teaching and consultation-liaison role. These sessions are required for third-year residents, who also attend other sessions such as practice management during these afternoons. Firstand second-year residents are invited but are not required to attend. There is an open-door policy allowing individuals to enter and leave without disturbing the flow of discussion, permitting all to learn from the experience of each one. The variable demands of patient care and other specialty curricula are recognized, but residents are encouraged to complete seminar presentation elements of competency requirements at these times. A series of didactic seminars related to each competency area is presented to the third-year residents. If there is no time for presentation of a case, a special review may be arranged with a member of the faculty. Other special learning experiences may be substituted for those defined by arrangement with the faculty. A log of clinical and didactic experiences directed toward achievement of the psychiatric competenties is kept by each resident and completed under the supervision of the Director of the Longitudinal Curriculum and the Director of the Family Medicine Residency (see Appendix). Evaluation is straightforward. Completion of the attitudinal, knowledge, and skills basis for each competency task to the satisfaction of the directors of the training program constitutes adequate performance. This approach avoids difficulties with varying theoretical, conceptual, and specialty frameworks in the training program.
Conclusion This curriculum is designed with the expectation of considerable involvement by family physicians in mental health care delivery. Psychiatry education is initiated early, before attitudes become fixed, to emphasize self-reliance and mental health problem-solving skills, to make the learning experience longitudinal, and to integrate psychiatric training into the rest of the residents’ curriculum. Seminars, clinical experience, and liaison with a mental health team are all utilized in the training design. The effectiveness of this training program will be studied over time to obtain needed data about the best
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teaching model for the mental family physician.
health
role of the
References 1. Meeting the Challenge of Family Practice: The Report of the Ad Hoc Committee on Education for Family Practice of the Council on Medical Education. Chicago, AMA, 1966 2. Citizens Commission on Graduate Medical Education: The Graduate Education of Physicians. Chicago, AMA, 1966 3. Coleman JV et al.: Integrating mental health services into primary medical care. Med Care 16:654661,1976 4. Task Panel on Mental Health: Nature and Scope of the Problems in Task Panel Reports Submitted to the President’s Commission on Mental Health. Vol. II, Washington, U.S. Government Printing Office, 1978 5. Fandetti DV, Gelfand DE: Attitudes toward symptoms and services in the ethnic family and neighborhood. Am J Orthopsychiatry 48:477486, 1978 6. Department of Health and Human Services: Report to the NIMH Work Group on Mental Health Training of Primary Care Providers. Washington, U.S. Government Printing Office, 1977 7. Hoeper EW et al.: Diagnosis of mental disorder in adults and increased use of health services in four outpatient settings. Am ] Psychiatry 137:207-211, 1980 8. Hesbacher PT, Rickels K, Morris RJ, Newman H, Rosenfeld H: Psychiatric illness in family practice. J Clin Psychiatry 41:6-10, 1980 9. Weismann MM, Myers JK, Harding I’S: Psychiatric disorders in a U.S. urban community: 1975-1976. Am J Psychiatry 135:459462, 1978 10. Pardes J: Future needs for psychiatrists and other mental health personnel. Arch Gen Psychiatry 36:1401-1409, 1979 Il. Neilson AC: The magnitude of declining psychiatry career choice. J Med Educ 54632437, 1979 12. Committee on Psychiatry and the Community: The Chronic Mental Patient in the Community. Group for Advancement of Psychiatry, New York, 1978 13. Sharfstein SS: Will community mental health survive in the 198Os? Am J Psychiatry 135:1363-1365, 1978 14. Hogarty GE: The plight of schizophrenics in modern treatment programs. Hosp Commun Psychiatry 22:197-203, 1971 15. Fink PJ et al.: Whatever happened to psychiatry? The deprofessionalization of community mental health centers. Am J Psychiatry 136:406409, 1979 HH et al.: Community mental health 16. Goldman centers and the treatment of severe mental disorder. Am J Psychiatry 137:83-86, 1980 17. Borus J: Neighborhood health centers as providers of primary mental health care. N Engl J Med 295:140145, 1976 18. Wyatt v. Sfickney, 325 F Supp 781 (MD Ala 1971) and 344 F Supp 373 (MD Ala 1972) Health Planning Administration: 19. Comprehensive State Plan for Services to the Mentally Ill. Alabama Department of Mental Health, 1980
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20. Comprehensive Health Planning Administration: Physician Manpower Study. Alabama Department of Mental Health, 1977 21. Comprehensive Health Planning Administration: Statistical Abstract. Alabama Dept. of Public Health, 1976 22. McGaghie WC et al.: Competency-Based Curriculum Development in Medical Education: An introduction. Public Health Papers No. 68. Geneva, World Health Organization, 1978 23. Knopke HJ: A framework for systematic educational planning. In Knopke, Diekelman (eds.). Approaches to Teaching Primary Health Care. St. Louis, C V Mosby Co. (in Press) 24. Segal A] et al.: Systematic Course Design for the Health Field. New York, Wiley, 1975 25. White KL, Williams TF, Greenberg BG: The ecology of medical care. N Engl J Med 265:885-892, 1961 26. Haggerty RJ: The university and primary medical care. N Engl J Med 281:416422, 1969 27. Geyman JP: The emerging profile of the residency trained family physician. J Fam Practice 11:717, 1980 28. Sivertson SE, Houser RH, Shropshire RW: Family Practices in Wisconsin: Implications for medical education and delivery of health care. Wisconsin Med J 73(12):S-170, 1974 29. Priest RG: Psychotherapy in general practice: expectations and experiences. Br J Med Psycho1 43:288-299, 1970 30. Werkman S, et al.: Common psychiatric problems in family practice. Psychosomatics 17:119-122, 1976 31. Fisher JV: Psychiatry and the family physician. Psychosomatics 19:523-527, 1978 32. Vaillant GE et al.: Some psychological vulnerabilities of physicians. N Engl J Med 282:365-370, 1972 33. Gurian H: A decade in rural psychiatry. Hosp Community Psychiatry 22:56-58, 1971 Cambridge, 34. Mazer M: People and Predicaments. Harvard University Press, 1976 35. Parker RC, Sorenson AA: The tides of rural physicians. The ebb and flow, or why physicians move out of and into small communities. Med Care 16:152-166, 1978 36. Drossman DA: Can the primary physician be better trained in the psychosocial dimensions of patient care? Int J Psychiatry Med 8:169-185, 1978 recognition of behavioral, 37. Brody DS: Physician psychological and social aspects of medical care. Arch Intern Med 140:1286-1289, 1980 38. McKegney FP, Weiner S: A consultation-liaison psychiatry clinical clerkship. Psychosom Med 38:4555, 1976 39. Goldberg RL, Haas MR, Eaton JS, Grubbs JH: Psychiatry and the primary care physician. JAMA 236:944-945, 1976 40. Fink PJ: The relationship of psychiatry to primary care. Am J Psychiatry 134:126-129, 1977 psychiatry: Past 41. Lipowski ZJ: Consultation-liaison failures and new opportunities. Gen Hosp Psychiatry 1:3-10, 1979 of the bio42. Engel GL: The clinical application psychosocial model. Am J Psychiatry 137:535-544, 1980
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of Family
Physicians
HM, Houpt JL: The applica49. Russell ML, Weinstein for tion competency-based education of consultation-liaison psychiatry: III. Implications. Int J Psychiatry Med 7:321-32Y, 1977 50. Trent I’S, Orleans CS, Houpt JL: Models for evaluating teaching in consultation-liaison psychiatry: I. An overview. Gen Hosp Psychiatry 1:104-107, iY79 51. Cohen-Cole SA: Training outcome in liaison psychiatry: Literature review and methodological prospects. Gen Hosp Psychiatry 2:282-289, 1980 52. Delbecq AL, Van de Veer AH, Gustafson DH: Group Techniques for Program Planning. Glenview, Scott, Foresman Company, 1975
43. Adams GL, Brachstein JR, Cheney CC, Friese JH, Tristan MI’: A primary care/mental health training and service model. Am J Psychiatry 135:1X-123,1978 44. Borus JF, Casserly MK: Psychiatrists and primary physicians: collaborative learning experiences in delivering primary care. Hosp Community Psychiatq 30:686-689, lY7Y 45. Hales RE: Primary care in psychiatry residency training. Gen Hosp Psychiatry 2:148-155, 1980 46. Bernstein RA: Liaison psychiatry: A model for medical care on a general hospital psychiatry unit. Gen Hosp Psychiatry 2:141-147, 1980 47. Houpt JL, Weinstein HM, Russell ML: The applicato education tion of competency-based consultation-liaison psychiatry: I. Data gathering and case formulation. Int ] Psychiatry Med 7:295-307, 1’377 48. Houpt JL, Weinstein HM, Russell ML: The applicafor competency-based education tion of consultation-liaison psychiatry: II. Intervention, knowledge and skills. Int J Psychiatry Med 7:309320, 1977
Appendix.
Training
L. Ralph P.O.
Jones,
M.D.
Box 6291
University,
AL 35486
Advanced Psychiatry Curriculum for Family Practice Residents Personal Log of Completed Competencies
Resident’s
Name
Completion of each competency will be certified by signature of the member of the faculty who supervised it. Twenty-four approvals are required for graduation. These should be completed at the rate of at least four per half year during all three years of the program. Competency achievements will be reviewed semi-annually, and residents who are substantially in arrears will be reported to the Residency Director for counseling. Special training experiences may be substituted for any requirement by advance arrangement with the Curriculum Director. The purpose of the case presentations is to demonstrate learning, to share with colleagues, and to stimulate seminar discussion. Case presentations need not be exhaustive, but rather should highlight what has been learned. These seminar case presentations will usually be done at the regular advanced curriculum seminars on Wednesday afternoons. Scheduling of these case presentations will be done with the Curriculum Director. If it is not possible to arrange a case presentation in this manner, the Curriculum Director will arrange a special quiz to fulfill this requirement. Three
Long-term
These
cases
Cases:
Medication,
are to be presented
Case # Case # Case # Crisis Counseling Present 2 cases to clinical
in a clinical
and Family
seminar
Counseling
emphasizing
primarv,
secondary,
seminars
emphasizing
primary,
secondary,
and tertiary
Approved Approved emphasizing Approved
and
tertiary
prevention
Date Date Date. ___.
Approved Approved Approved
Case # Case # Management of Sexual Problems Present one case to clinical seminar, Case #
Individual
prevention
secondary,
and tertiary
prevention Date
__-
aspects.
Date Date primary,
aspects.
-_-___
aspects. __-___
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4. Family Dynamics a. Extensive
and Counseling
evaluation
Skills
of 1 family with home visit Date
Approved b. Presentation
of above case evaluation
for seminar
Approved 5. Problems of Family Life Participation in 3 seminars covering family life problems Identify Seminars 6. Psychiatric Problems of Children and Adolescents Work up and present two cases to clinical seminar
Date
Approved---_--__
Date
Date Approved Case # Date Approved Case # 7. Psycho-social-somatic Relationships in Health and Disease Management of a “psychosomatic” case and presentation to clinical seminar Date Approved Case # 8. Management of Chronic Disability a. Work up and present case to clinical seminar emphasizing secondary and tertiary prevention Date Approved Case # b. Work up and present for seminar discussion one case from Partlow School Date Approved Case # 9. Forensic Psychiatry a. Court appearance as expert witness Date Approved Case # b. Presentation of a case to clinical seminar Date Approved Case # 10. Substance Abuse a. Long-term management Case # b. Attendance
of a case and presentation to clinical seminar Approved at 2 AA meetings and discussion of this experience at a clinical seminar Approved
Date Date
11. Physicians’ Mental Health Problems Case presentation to clinical seminar Date
Approved 12. Community Mental Health Visit 1 community mental health facility and discuss this visit in a clinical seminar Approved
Date
13. Occupational Psychiatry Presentation in a clinical seminar of an industrial accident Approved Case #
Date
14. Mental Hygiene and Management Skills Presentation to 1 clinical seminar of an administrative Approved
198
case
problem with psychiatric
overtones Date
aspects
Ph.D.
Richard R. Parlour, M.D. Russell L. Anderson,
M.D.
The University of Alabama School of Medicine,
College of Community
Recognizing the important role offamily physicians in mental health care, psychiatry and family medicine faculty developed a psychiatric curriculum for family medicine residents. The collaborative effort utilized graduate interviews, literature review, and specialized group techniques to develop a competency-bused curriculum that begins early in the residency, is integrated longitudinally into the remainder of the curriculum, and utilizes seminars, clinical experience,and liaison with a mental health team in the training design. Abstract:
For a number of years, a consensus has prevailed regarding the need to address decisively the maldistribution of physicians with respect to their specialty or functional role relative to the needs of the population (1, 2). Primary care has become the organizing principle for health care delivery in the 1980s. By serving as physician of first contact, by rendering comprehensive care and continuity of care, and by coordinating health care delivery, the primary care physirian-especially the family physician-was envisioned to be capable of filling the gaps in the American health care delivery system. Coleman and Patrick suggested that the inclusion of mental health services as an integral component of primary health care offers the only feasible means to improve substantially the mental health services for the population as a whole (3). This conclusion was amply supported by the report of
This work was supported in part by National Institute of Mental Health Grant lTOlMH16016-OlAlPI. General Hospital Psychiatry 3, 189-398, lY81 @ Elsevier North Holland, Inc., 1981 52 Vanderbilt Avenue, New York, NY 10017
Health Sciences,
University,
Alabama
the President’s Commission on Mental Health (4). Studies of patients’ attitudes about mental health services also support this role for the family physician (5). Furthermore, even though only 2% of patient visits to nonpsychiatrists involve psychotherapy/therapeutic listening, because of their absolute numbers, these physicians provide fully 46% of all psychotherapy/therapeutic listening offered to patients (6). Hoeper et al. found that patients with mental disorders utilize general health services two to four times more than patients without mental disorders. It was concluded that funding for somatic medical care pays for a significant amount of mental care not defined or reported as such (7). Hesbacher et al. surveyed the prevalence of severely symptomatic psychiatric disorders in six family practices. Independent assessments by patients and their physicians revealed 10 '3'0and 21% prevalence, respectively (8). Weissman et al. found a similar prevalence of psychiatric illness in an urban community. The majority of patients were suffering from depression (9). With the high rate of mental disorder documented in primary care patients, psychiatric educational and service backup will be increasingly needed if the thrust of primary care is to succeed. Although psychiatrists will be needed in increasing numbers for administrative, treatment, consultation-liaison, and education functions, there has been a steady decline in the absolute numbers and percentages of U.S. graduates entering psychiatry (10). Neilsen predicted that less than 2% 189 ISSN
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L. R. Jones et al.
of all medical students would choose a psychiatric career in 1980 (11). The Health Professions Educational Assistance Act of 1976 severely restricted the number of foreign medical graduates who may enter the United States for residency training. The combination of a drop in the number of residents entering psychiatry and the numbers of foreign medical graduates allowed to enter the field will produce a severe shortage of needed psychiatrists. One result of the shortfall in psychiatric manpower is that primary care physicians’ mental health role expectations are increasing. The characteristics of mental health care delivery have changed radically in the past three decades. Active programs of inpatient treatment, the wide application of psychopharmacologic therapy, the emphasis on community-based care, and right to treatment legislation have all contributed to deinstitutionalization (12). But community-based services in the specialty mental health sector have not developed at a sufficient rate to allow this policy to be implemented fully. Only one-third of community mental health centers planned have been opened (13). It has been charged, furthermore, that community mental health centers have failed to serve the most seriously disabled deinstitutionalized patients (14-16). In the midst of an apparent trend to close the state hospitals and “dump” chronically ill patients onto unprepared communities, the movement to integrate mental health services with primary health care delivery has gained momentum (17). Though the rehabilitation and aftercare role for the family physician has increased in importance, the division of responsibility for maintaining chronically ill patients in the community has remained ill-defined (6).
Mental Health Care Delivery in Alabama Alabama has not been spared from a shortage and maldistribution of physicians. This largely rural state is forty-ninth in physician/population ratio and contains only one-third the national average of psychiatrists per 100,000 population. The state mental health system has been under federal court order for eight years to conform to a detailed set of minimum constitutional standards for adequate treatment of the mentally ill (18). In 1980 it was found to be not in compliance with the order. With 64 % of the population on farms or in small towns, only 23% of the few available psychiatrists and 15% of the physicians generally practice in these areas. Yet the indicators for high risk and increased need for
mental health services, such as qualification for poverty designation, the percentage of aging, overcrowded housing, and high rates of admission to state hospitals, suicide, and alcoholism, are most prevalent in rural areas (19, 20). Undereducated poor people often lack the skill and knowledge to obtain even those services that are available. Per capita income in Alabama is only 80% of the national average, and approximately one-third of the age group over 25 has completed less than nine years of formal education (21). These patients expect general physicians to help them with emotional disorders. The conclusion is inescapable that family medicine residents who will enter the underserved areas of Alabama must be trained to recognize, treat, and properly refer psychiatric patients. The Family Medicine Residency at the University of Alabama College of Community Health Sciences was established in 1974 to prepare physicians to meet the health care needs of rural and underserved areas of the state. The residency had graduated four classes of family physicians when the psychiatry faculty undertook a complete evaluation of their share of the curriculum developed during the first seven years. Through this self-assessment, the faculty determined that additional experiences were needed if graduates of the program were to address the state’s mental health needs and the mental health needs and the mental health manpower shortage in the state and region. To develop efficient and effective psychiatric components for the Family Medicine residency, the psychiatric faculty in the College began a systematic redevelopment of their curriculum, focusing on the following questions: 1.
What are the mental health elements of the professional role of family physicians?
2.
How can these elements of professional roles best be incorporated in the teaching/learning process of the residency?
Program Development Process Early in the faculty’s educational self-assessment, it was decided that the optimal teaching/learning framework would be a competency-based curriculum (22). This provides the means for designing educational experiences around anticipated role functions, and permits maximum flexibility in terms of time, resources, and logistics (23). Because curriculum serves to define professional roles and
Psychiatric
elements of those roles, the process of curriculum development is as significant as its product. Of the many methods described for defining competenties, three were chosen for use in this developmental process, for the amount of information they could provide and their applicability to the residency program: interviews of former residents in practice, a review of the literature, and a modified delphi-nominal group technique (24).
Graduate Resident Interview residents from the first four Representative graduating classes met with College faculty to discuss their experiences in the residency and their professional experiences since they began practice. They represented solo, family practice group, and multispecialty group practices. All the residents felt additional mental health experience to be a priority for the resident curriculum. They were sensitive to mental health problems presented by their patients, but they felt unable to manage many of them adequately. Significant problem areas identified were talking with patients and conducting psychotherapy for marital or divorce problems, sexual problems, psychophysiologic or hypochondriacal complaints. The statement of one graduate summarized these perceptions: “One of the hardest things I have to deal with is the middle-aged woman with a headache.”
Review of the Literature: The Dimensions of a Mental Health Role Efforts to increase the role of the primary care physician in mental health services must recognize the characteristics of their practices. It is noteworthy that patients encountered in urban, sophisticated university hospital services represent only 0.4% of patients seen by physicians and one of 1000 patients at risk each month (25). Ninety to ninetyfive percent of all doctor-patient contacts occur at the primary care level (26). Family physicians see an average of 160 patients in a work week averaging 60 hours, refer only 2.4% of their patients, hospitalize 2%, and provide counseling or psychotherapy in 18% of patient visits (27, 28). Priest estimated that the pragmatic general practitioner spends only seven minutes per psychotherapy patient visit and no more than one hour per month (29). Werkman et al. reported that family physicians encounter the following problems in order of frequency: marital depression, hypochondriasis, alproblems,
Training
of Family
Physicians
coholism, chronic illness, and anxiety-tension states (30). Methods used to deal with emotional and psychiatric illnesses included the following, in decreasing order: advice and reassurance, tranquilizers, antidepressants, sedatives, and psychotherapy (31). Another consideration emphasized by Fisher is the need for the family physician to understand himself (31). A number of issues confront the family physician attempting to deliver effective mental health care. First, he must cope with the personal adjustment to living in an underserved, usually rural area. The processes of personal maturation and professional identity development continue after the physician begins to practice. Problems may arise with his marriage, with his children, or with substance abuse. He may develop an emotional disorder himself, for which he may be reluctant to seek help (32). Any problem that occurs is complicated by his high visibility in rural settings. It may be difficult for a middle-class, urbantrained professional to understand, much less fulfill, the therapeutic requirements of economically disadvantaged, geographically isolated, or ethnically distinct patients (33). Lessons from rural practicing psychiatrists, therefore, are useful (33, 34). The rural family physician providing mental health care must be aware of transference and countertransference feelings and attitudes which occur and must be prepared for the potential complexity of social or business interactions with individuals who are also patients. Physicians practicing in rural areas may feel isolated from support resources and opportunities for professional growth. Unexpected emotional reactions in patients may make the family physician acutely aware of his need for a mental health team or liaison relationship. Traumatic experiences may render the doctor unwilling to diagnose discernible mental disorders, to undertake needed therapeutic measures, or to refer thereafter. Parker and Sorenson have found that inadequate professional support is one of the major reasons why otherwise well-trained and well-motivated physicians leave rural areas for more urban settings (35). These data suggest practical issues in mental health care delivery and areas of important emphasis in mental health curricula for primary care residents. Family physicians must be prepared for a broadly defined role in mental health care delivery and need to be trained to recognize and diagnose mental disorders, to manage certain patients, to recognize indications for referral to psychiatrists, to
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conduct psychotherapy with some patients, to prescribe psychotropic drugs appropriately, to utilize social intervention techniques, and to function as part of an interdisciplinary health team, maintaining professional liaison with other specialists.
Implications for Design of a Curriculm There are many difficulties in constructing a training program which addresses patients’ needs, as well as the scope of preparedness, envisioned for the family physician. Drossman has lamented that the changes in medical education engendered by new technology have emphasized basic science knowledge and technical competence at the expense of understanding mental health dimensions. He doubts whether comprehensive and continuous care can be rendered effectively without these concepts (36). In response, the focus of clinical management in training programs, especially with chronically ill ambulatory patients, has been redirected to behavioral, psychosocial, and psychiatric elements associated with medical disorder in recent years. Brody, however, discovered that primary care physicians, who were informed of inclusion in a study, failed to recognize 79% of their patients’ noncompliance with medications, 34% of psychiatric illness, and 76% of patients’ recent stressful events-even with weekly performance review (37). Possible explanations included attitudinal, knowledge, and skills dimensions, which were not considered adequate justification. McKegney and Weiner believed that these failures result from “irrelevant” features of training programs (38). Much of learning is state dependent; information learned in one state is best recalled in the same state. This means that traditional teaching of psychiatry with “psychiatric” patients on psychiatric services in a specialized context results in little “carry-over learning” of psychiatric principles referrable to nonpsychiatric patients. Training programs have been subsequently designed to weave behavioral, psychosocial, and psychiatric elements into the entire fabric of the curriculum. The best teaching/learning may be achieved in a consultation-liaison setting, with emphasis on biopsychosocial aspects of illness or injury and on the quality of patient interviewing and case formulation (39-41). Engel has further argued that use of the biopsychosocial model has enabled application of the scientific method to areas previously neglected by the biomedical model (42). Interprofessional antagonisms that often de192
velop during training may be minimized by designing collaborative learning experiences in interdisciplinary settings. Learning and efficient utilization of resources for patient care are increased by the availability of respected clinicians who model collaborative professional roles while teaching appropriate knowledge and skills. This approach has been extended from primary care training programs to psychiatry residency, and from psychiatric liaison to medical liaison in psychiatric clinics and hospital units (4346). The NIMH work group on the mental health training of primary care providers has outlined necessary knowledge, attitudes, and skills for construction of educational goals in training programs. The family physician must master a basic core of knowledge that will permit patients to be viewed as whole persons whose biological well-being is associated with their psychosocial well-being. The rationale underlying diagnosis, treatment, or referral in mental disorders must also be understood. Many patients who are most in need of mental health services encounter biased attitudes and avoidance by care givers. These include the old, the poor, members of minority and ethnic groups, the chronically mentally ill, the retarded, or substance abusers. Training programs should offer adequate role models for active involvement with these patient groups, in order to guard against the hopelessness and avoidance these patients often encounter. Some of these attitudinal problems may be addressed in training as a need for greater selfawareness and the ability to avoid overidentification with patients, over-involvement with their problems, moral judgments, and so on. Skills are needed in diagnosis, treatment, prevention, and rehabilitation, with special emphasis on recognition of psychiatric emergencies and serious mental illness. Intrinsic to the contribution of the family physician is the recognition of his or her skill limitations and role boundaries. Another dilemma in designing a curriculum, however, is that no matter how well developed and focused his or her skills, the family physician may encounter inadequate access to secondary and tertiary mental health care backup in many communities. This circumstance will strain the boundaries of the role the family physician is prepared to fill or force patients to forgo services they need (6). Although a consensus exists about the relevance of a consultation-liaison setting for mental health training of family physicians, a framework is required around which to unify the diverse elements
Psychiatric Training of Family Physicians
of the curriculum. Houpt et al. have developed a competency-based model that emphasizes behavioral definitions of competence in knowledge, skills, and attitudes from which behavioral objectives and evaluation methods may be derived. The competency-based model doesn’t adhere to one theoretical or conceptual framework, making it readily applicable to an interdisciplinary training setting. Behavioral objectives may serve as a focus for teaching/supervision in family medicine resident training, such that both teacher and resident are aware of areas of strength and weakness in the mastery of the curriculum. The flexible nature of the competency areas may allow completion of mental health training objectives while rotating on other specialty services (4749). Recently, attention has been focused on the special issues that make evaluation in consultation-liaison programs difficult. Conceptual frameworks for training outcome that consider variability in training environments are proposed which may also be useful for research on curriculum design and its effectiveness (50, 51).
Modified DelphiNominal Group Techniques Family Medicine and Psychiatry faculty met together on a semi-weekly basis over the course of two months to arrive at a mutually defined set of psychiatric/mental health competencies for family practitioners; to determine the requisite educational experiences necessary to meet these competencies in residency; and to resolve necessary and appropriate logistical details. The process employed was similar to the delphi technique in that the same individuals constituted the respondent sample. The process began with a semistructured solicitation compilation of ideas which were subsequently categorized and refined through several iterations (52). The process was also similar to the nominal group process in that the two faculty groups met together each time in the same location and were led in their deliberative process by a moderator (52). Among the role functions and responsibilities mutually identified and described were management of long-term psychiatric patients and their families, crisis counseling, common problems of family life, and sex counseling. As these functions and responsibilities were defined in the form of competencies, a variety of educational experiences and teaching/learning methodologies were established to accomplish them. It was decided that residents would see their family medicine patients requiring mental health care in the psychiatric
suite in the Family Practice Clinic, under the cooperative supervision of the family practice and psychiatric faculty.
Psychiatric Education for Family Medicine Residents Family Medicine Curriculum in Basic Psychiatry The psychiatric
curriculum resulting from this study begins with a two-month block in the first year, constituting part of the program’s core curriculum. The purpose of this block is to establish a knowledge and skill base for the longitudinal, competency-based curriculum. Residents rotate in various clinical settings under close teaching supervision; service and didactic components of the curriculum are balanced to avoid overcrowding either one. Teaching/learning objectives designed to organize basic mental health knowledge, skills, and therapeutic attitudes include the following: 1. Increase skill in psychiatric data gathering, diagnosis, and treatment planning 2. Understand the process of human psychological development, including adaptational hazards and normal and abnormal adaptational variants 3. Recognize and manage psychiatric emergencies 4. Be able to design an appropriate mental health treatment plan in a primary care setting and make adequate referral 5. Learn appropriate methods of collaboration and treatment planning with nonmedical mental health professionals 6. Utilize psychopharmacology and brief therapy modalities in a primary care practice 7. Understand the legal aspects of involuntary treatment and confidentiality 8. Recognize the psychological reactions of the normal patient and his family to the stress of illness or hospitalization Residents spend the first month focusing on the psychiatry dimension of the family medicine program. They see outpatients in the outpatient suites and admit patients requiring hospitalization to the psychiatry unit of a community general hospital. They participate actively in consultation-liaison activities with colleagues on other services and participate in a close working relationship with the community health center serving the catchment area. Health and mental health services are integrated where possible, with the supervised resident 193
L. R. Jones et al.
Table 1. Advanced
Psychiatry
Curriculum
Competencies
Competencies 1. Manage long-term
families, including
psychiatric patients and their individual and family counseling
2. Develop skill in crisis counseling priate for family practice 3. Manage common
Method
techniques
Select 3 patients with chronic psychiatric disorders for longitudinal management of at least 6 months each
appro-
Select 2 patients with stress-related disorders; design crisis intervention to reduce symptoms, restore selfesteem, return to effective functioning Work up 1 patient and lead a seminar on sexual disorders
sexual problems
patterns of 4. Recognize normal and dysfunctional family life and develop family counseling skills
Complete an evaluation of one family, including a home visit; interview the family in seminar, explaining the strengths and weaknesses of family functioning, anticipated problems and management
5. Manage common
Participate in seminars on management problems and present a case
problems
of family life
6. Diagnose and manage psychiatric children and adolescents
problems
Evaluate 2 children with psychiatric present diagnostic and management psychiatry seminars
of
7. Understand relationships between psychosocial physical aspects of disease
and
of family life
disorders and issues in child
Work up a case of “illness claiming” months, and present to seminar
behavior,
follow 6
8. Manage psychiatric aspects of chronic disability commonly seen in family practice, including blindness, deafness, cerebral palsy, chronic brain syndrome, mental retardation, or any chronic illness
a. Participate in seminars specifically focused on chronic illness b. Present a case of chronic disability demonstrating appropriate management skills Evaluate 1 student at a school for the developmentally C. disabled for presentation as in (b) above
9. Prepare for and make a court appearance
a. Attend the seminars on psychiatry b. Make at least one court appearance
10. Identify and manage common types of substance seen in family practice including alcoholism
abuse
a. Participate in seminars focused on substance abuse b. Manage for 6 months 1 case of chronic substance abuse and demonstrate understanding of the addiction process and appropriate management; present to seminar C. Attend an AA meeting
11. Recognize and be able to manage the mental health hazards of being a physician
Attend seminars designed to elucidate physicians’ mental health problems; present a case
12. Understand community mental health theory and practices and know how family doctors can participate in community mental health
a. Participate in didactic symposia provided in curriculum b. Visit one community mental health center to observe facilities, staff, patients, and programs
13. Recognize and manage the common syndromes and psychodynamics of occupational psychiatry, evaluation of psychiatry disability, and special management problems presented by these cases
a. Participate in didactic and clinical seminars on occupational psychiatry b. Present a case in which occupational factors are substantially related to mental disorder and propose management
14. Understand the common styles of management and the mental health factors in administration, including the physicians’ office
Participate in seminars ministration
194
on the psychiatric
aspects of ad-
Psychiatric
in a central role in psychiatric evaluation, triage, and treatment. During the second month, residents continue work in outpatient clinics, and they are assigned to a treatment team in an acute care unit of a psychiatric hospital where they manage a small number of seriously ill psychiatric patients under the teaching supervision of a faculty psychiatrist. The residents are expected to learn how to work with the treatment team in evaluation, treatment, and discharge planning on a daily basis and in team meetings. Their tour of duty includes four half-days in an alcoholism treatment unit and four half-days in a psychiatric hospital for children.
Longitudinal,
Competency-Based
Curriculum
This curriculum is based on the expectations that family physicians are principal resources for comprehensive, continuous care to their patients, and that family medicine residents require long-term, ongoing consultation and liaison relationships with psychiatry and behavioral science faculty to implement a biopsychosocial model of illness and injury management. Goals in this training program are defined in terms of competencies, specific tasks embodying knowledge, skills, and attitudes essential to a strong mental health role. Completion of the required competencies may begin on the first day of the residency independent of formal assignment to the psychiatry service; all must be achieved for graduation. With a focus on long-range management, residents often become acquainted with patients from their clinics before diagnosis of an identifiable mental disorder is made, and actively manage these patients in a consultation-liaison teaching relationship with psychiatry, behavioral science, and family medicine faculty. Long-term follow-up of psychiatric patients is another important dimension of this curriculum involving primary, secondary, and tertiary aspects of prevention. It is expected that the majority of competency areas will be addressed in the resident’s experience of outpatient and inpatient treatment of his or her patients. Psychiatry faculty may refer specific cases for residents if needed to complete competency requirements. Conversely, residents may refer some difficult patients for management in the psychiatry clinic as part of the basic psychiatry curriculum. Although methods for attainment of the competenties are specified, considerable flexibility is intended. The resident may choose the timing, the
Training
of Family
Physicians
supervision, and treatment setting in each area. The competencies and their methods of attainment are listed in Table 1. Every Wednesday afternoon, a combined clinical and didactic meeting is held, attended by psychiatry and behavioral science faculty who function in a teaching and consultation-liaison role. These sessions are required for third-year residents, who also attend other sessions such as practice management during these afternoons. Firstand second-year residents are invited but are not required to attend. There is an open-door policy allowing individuals to enter and leave without disturbing the flow of discussion, permitting all to learn from the experience of each one. The variable demands of patient care and other specialty curricula are recognized, but residents are encouraged to complete seminar presentation elements of competency requirements at these times. A series of didactic seminars related to each competency area is presented to the third-year residents. If there is no time for presentation of a case, a special review may be arranged with a member of the faculty. Other special learning experiences may be substituted for those defined by arrangement with the faculty. A log of clinical and didactic experiences directed toward achievement of the psychiatric competenties is kept by each resident and completed under the supervision of the Director of the Longitudinal Curriculum and the Director of the Family Medicine Residency (see Appendix). Evaluation is straightforward. Completion of the attitudinal, knowledge, and skills basis for each competency task to the satisfaction of the directors of the training program constitutes adequate performance. This approach avoids difficulties with varying theoretical, conceptual, and specialty frameworks in the training program.
Conclusion This curriculum is designed with the expectation of considerable involvement by family physicians in mental health care delivery. Psychiatry education is initiated early, before attitudes become fixed, to emphasize self-reliance and mental health problem-solving skills, to make the learning experience longitudinal, and to integrate psychiatric training into the rest of the residents’ curriculum. Seminars, clinical experience, and liaison with a mental health team are all utilized in the training design. The effectiveness of this training program will be studied over time to obtain needed data about the best
195
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teaching model for the mental family physician.
health
role of the
References 1. Meeting the Challenge of Family Practice: The Report of the Ad Hoc Committee on Education for Family Practice of the Council on Medical Education. Chicago, AMA, 1966 2. Citizens Commission on Graduate Medical Education: The Graduate Education of Physicians. Chicago, AMA, 1966 3. Coleman JV et al.: Integrating mental health services into primary medical care. Med Care 16:654661,1976 4. Task Panel on Mental Health: Nature and Scope of the Problems in Task Panel Reports Submitted to the President’s Commission on Mental Health. Vol. II, Washington, U.S. Government Printing Office, 1978 5. Fandetti DV, Gelfand DE: Attitudes toward symptoms and services in the ethnic family and neighborhood. Am J Orthopsychiatry 48:477486, 1978 6. Department of Health and Human Services: Report to the NIMH Work Group on Mental Health Training of Primary Care Providers. Washington, U.S. Government Printing Office, 1977 7. Hoeper EW et al.: Diagnosis of mental disorder in adults and increased use of health services in four outpatient settings. Am ] Psychiatry 137:207-211, 1980 8. Hesbacher PT, Rickels K, Morris RJ, Newman H, Rosenfeld H: Psychiatric illness in family practice. J Clin Psychiatry 41:6-10, 1980 9. Weismann MM, Myers JK, Harding I’S: Psychiatric disorders in a U.S. urban community: 1975-1976. Am J Psychiatry 135:459462, 1978 10. Pardes J: Future needs for psychiatrists and other mental health personnel. Arch Gen Psychiatry 36:1401-1409, 1979 Il. Neilson AC: The magnitude of declining psychiatry career choice. J Med Educ 54632437, 1979 12. Committee on Psychiatry and the Community: The Chronic Mental Patient in the Community. Group for Advancement of Psychiatry, New York, 1978 13. Sharfstein SS: Will community mental health survive in the 198Os? Am J Psychiatry 135:1363-1365, 1978 14. Hogarty GE: The plight of schizophrenics in modern treatment programs. Hosp Commun Psychiatry 22:197-203, 1971 15. Fink PJ et al.: Whatever happened to psychiatry? The deprofessionalization of community mental health centers. Am J Psychiatry 136:406409, 1979 HH et al.: Community mental health 16. Goldman centers and the treatment of severe mental disorder. Am J Psychiatry 137:83-86, 1980 17. Borus J: Neighborhood health centers as providers of primary mental health care. N Engl J Med 295:140145, 1976 18. Wyatt v. Sfickney, 325 F Supp 781 (MD Ala 1971) and 344 F Supp 373 (MD Ala 1972) Health Planning Administration: 19. Comprehensive State Plan for Services to the Mentally Ill. Alabama Department of Mental Health, 1980
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20. Comprehensive Health Planning Administration: Physician Manpower Study. Alabama Department of Mental Health, 1977 21. Comprehensive Health Planning Administration: Statistical Abstract. Alabama Dept. of Public Health, 1976 22. McGaghie WC et al.: Competency-Based Curriculum Development in Medical Education: An introduction. Public Health Papers No. 68. Geneva, World Health Organization, 1978 23. Knopke HJ: A framework for systematic educational planning. In Knopke, Diekelman (eds.). Approaches to Teaching Primary Health Care. St. Louis, C V Mosby Co. (in Press) 24. Segal A] et al.: Systematic Course Design for the Health Field. New York, Wiley, 1975 25. White KL, Williams TF, Greenberg BG: The ecology of medical care. N Engl J Med 265:885-892, 1961 26. Haggerty RJ: The university and primary medical care. N Engl J Med 281:416422, 1969 27. Geyman JP: The emerging profile of the residency trained family physician. J Fam Practice 11:717, 1980 28. Sivertson SE, Houser RH, Shropshire RW: Family Practices in Wisconsin: Implications for medical education and delivery of health care. Wisconsin Med J 73(12):S-170, 1974 29. Priest RG: Psychotherapy in general practice: expectations and experiences. Br J Med Psycho1 43:288-299, 1970 30. Werkman S, et al.: Common psychiatric problems in family practice. Psychosomatics 17:119-122, 1976 31. Fisher JV: Psychiatry and the family physician. Psychosomatics 19:523-527, 1978 32. Vaillant GE et al.: Some psychological vulnerabilities of physicians. N Engl J Med 282:365-370, 1972 33. Gurian H: A decade in rural psychiatry. Hosp Community Psychiatry 22:56-58, 1971 Cambridge, 34. Mazer M: People and Predicaments. Harvard University Press, 1976 35. Parker RC, Sorenson AA: The tides of rural physicians. The ebb and flow, or why physicians move out of and into small communities. Med Care 16:152-166, 1978 36. Drossman DA: Can the primary physician be better trained in the psychosocial dimensions of patient care? Int J Psychiatry Med 8:169-185, 1978 recognition of behavioral, 37. Brody DS: Physician psychological and social aspects of medical care. Arch Intern Med 140:1286-1289, 1980 38. McKegney FP, Weiner S: A consultation-liaison psychiatry clinical clerkship. Psychosom Med 38:4555, 1976 39. Goldberg RL, Haas MR, Eaton JS, Grubbs JH: Psychiatry and the primary care physician. JAMA 236:944-945, 1976 40. Fink PJ: The relationship of psychiatry to primary care. Am J Psychiatry 134:126-129, 1977 psychiatry: Past 41. Lipowski ZJ: Consultation-liaison failures and new opportunities. Gen Hosp Psychiatry 1:3-10, 1979 of the bio42. Engel GL: The clinical application psychosocial model. Am J Psychiatry 137:535-544, 1980
Psychiatric
of Family
Physicians
HM, Houpt JL: The applica49. Russell ML, Weinstein for tion competency-based education of consultation-liaison psychiatry: III. Implications. Int J Psychiatry Med 7:321-32Y, 1977 50. Trent I’S, Orleans CS, Houpt JL: Models for evaluating teaching in consultation-liaison psychiatry: I. An overview. Gen Hosp Psychiatry 1:104-107, iY79 51. Cohen-Cole SA: Training outcome in liaison psychiatry: Literature review and methodological prospects. Gen Hosp Psychiatry 2:282-289, 1980 52. Delbecq AL, Van de Veer AH, Gustafson DH: Group Techniques for Program Planning. Glenview, Scott, Foresman Company, 1975
43. Adams GL, Brachstein JR, Cheney CC, Friese JH, Tristan MI’: A primary care/mental health training and service model. Am J Psychiatry 135:1X-123,1978 44. Borus JF, Casserly MK: Psychiatrists and primary physicians: collaborative learning experiences in delivering primary care. Hosp Community Psychiatq 30:686-689, lY7Y 45. Hales RE: Primary care in psychiatry residency training. Gen Hosp Psychiatry 2:148-155, 1980 46. Bernstein RA: Liaison psychiatry: A model for medical care on a general hospital psychiatry unit. Gen Hosp Psychiatry 2:141-147, 1980 47. Houpt JL, Weinstein HM, Russell ML: The applicato education tion of competency-based consultation-liaison psychiatry: I. Data gathering and case formulation. Int ] Psychiatry Med 7:295-307, 1’377 48. Houpt JL, Weinstein HM, Russell ML: The applicafor competency-based education tion of consultation-liaison psychiatry: II. Intervention, knowledge and skills. Int J Psychiatry Med 7:309320, 1977
Appendix.
Training
L. Ralph P.O.
Jones,
M.D.
Box 6291
University,
AL 35486
Advanced Psychiatry Curriculum for Family Practice Residents Personal Log of Completed Competencies
Resident’s
Name
Completion of each competency will be certified by signature of the member of the faculty who supervised it. Twenty-four approvals are required for graduation. These should be completed at the rate of at least four per half year during all three years of the program. Competency achievements will be reviewed semi-annually, and residents who are substantially in arrears will be reported to the Residency Director for counseling. Special training experiences may be substituted for any requirement by advance arrangement with the Curriculum Director. The purpose of the case presentations is to demonstrate learning, to share with colleagues, and to stimulate seminar discussion. Case presentations need not be exhaustive, but rather should highlight what has been learned. These seminar case presentations will usually be done at the regular advanced curriculum seminars on Wednesday afternoons. Scheduling of these case presentations will be done with the Curriculum Director. If it is not possible to arrange a case presentation in this manner, the Curriculum Director will arrange a special quiz to fulfill this requirement. Three
Long-term
These
cases
Cases:
Medication,
are to be presented
Case # Case # Case # Crisis Counseling Present 2 cases to clinical
in a clinical
and Family
seminar
Counseling
emphasizing
primarv,
secondary,
seminars
emphasizing
primary,
secondary,
and tertiary
Approved Approved emphasizing Approved
and
tertiary
prevention
Date Date Date. ___.
Approved Approved Approved
Case # Case # Management of Sexual Problems Present one case to clinical seminar, Case #
Individual
prevention
secondary,
and tertiary
prevention Date
__-
aspects.
Date Date primary,
aspects.
-_-___
aspects. __-___
197
L. R. Jones et al.
4. Family Dynamics a. Extensive
and Counseling
evaluation
Skills
of 1 family with home visit Date
Approved b. Presentation
of above case evaluation
for seminar
Approved 5. Problems of Family Life Participation in 3 seminars covering family life problems Identify Seminars 6. Psychiatric Problems of Children and Adolescents Work up and present two cases to clinical seminar
Date
Approved---_--__
Date
Date Approved Case # Date Approved Case # 7. Psycho-social-somatic Relationships in Health and Disease Management of a “psychosomatic” case and presentation to clinical seminar Date Approved Case # 8. Management of Chronic Disability a. Work up and present case to clinical seminar emphasizing secondary and tertiary prevention Date Approved Case # b. Work up and present for seminar discussion one case from Partlow School Date Approved Case # 9. Forensic Psychiatry a. Court appearance as expert witness Date Approved Case # b. Presentation of a case to clinical seminar Date Approved Case # 10. Substance Abuse a. Long-term management Case # b. Attendance
of a case and presentation to clinical seminar Approved at 2 AA meetings and discussion of this experience at a clinical seminar Approved
Date Date
11. Physicians’ Mental Health Problems Case presentation to clinical seminar Date
Approved 12. Community Mental Health Visit 1 community mental health facility and discuss this visit in a clinical seminar Approved
Date
13. Occupational Psychiatry Presentation in a clinical seminar of an industrial accident Approved Case #
Date
14. Mental Hygiene and Management Skills Presentation to 1 clinical seminar of an administrative Approved
198
case
problem with psychiatric
overtones Date
aspects